Title: Focal Lesions
1Focal Lesions
2Left Hemisphere Processing
- The left hemisphere plays a major role in the
neural processes governing the production and
comprehension of propositional (meaningful)
language. - For this reason, it has been designated the
dominant hemisphere. - It is well-suited to processing linguistic
elements and information sequentially and
analytically. - Cortical representations of linguistic processes
are not static nor are they subject to exact
demarcations. - Rather, language representation exists in
functional fields within which specific abilities
(modules) overlap with other linguistic and
symbolic abilities.
3Quick Review of Modules
- Very specific communication and cognitive
abilities are localized in modules at different
levels of synaptic connection. - At the first synaptic level, sensation is mapped
by finely tuned neurons into a primary dimension
for vision, the dimension is retinotopic for
audition, the dimension is tonotopic. - The second synaptic level mediates the more
differentiated extraction of specific attributes,
such as color and motion frequency, intensity,
and periodicity. - Motivational, emotional, and attentional
modulations are relatively weak at the first two
synaptic levels.
4Quick Review of Modules
- However, motivational, emotional, and attentional
modulations become increasingly more influential
at higher synaptic levels where they help to
depict a version of the world based on
significance rather than appearance. - The third and fourth synaptic levels play
critical roles in the perceptual encoding of
faces, objects, words, and extrapersonal targets
by ensembles of coarsely tuned neurons. - The fifth and sixth synaptic levels are found in
the heteromodal, paralimbic, and limbic regions
of the cerebral cortex. - These transmodal areas are critical for
transforming perception into recognition, words
into meaning, scenes and events into experiences,
and spatial locations into targets for
explorations.
5Quick Review of Network Theory
- Transmodal areas constitute epicenters for
large-scale distributed networks. - All large-scale networks have similar
organization they all have two interconnected
epicenters. - If one epicenter member of the pair is
interconnected with additional cortical areas,
then the other epicenter member is interconnected
also with the same additional cortical areas. - Consequently, if one epicenter transmits a
message, the other epicenter will receive it
directly from its pair, but also indirectly from
the vantage point of the additional cortical
areas.
6Quick Review of Network Theory
- Language processing, then, is subserved by
regions that form integrated cerebral networks
based on neural intercommunications. - The components of these networks can be divided
into critical versus participating areas. - Lesions which irreversibly impair performance in
a cognitive domain help to identify network
components that are critical for its integrity. - Other areas may participate in the coordination
of certain aspects of tasks in the same domain.
7The Perisylvian Network
- The two epicenters of the language network are
Brocas and Wernickes areas. - Brocas area includes the premotor region (BA44)
and the adjacent heteromodal fields of BA 45-47. - Brocas area displays relative specialization for
the articulatory, syntactic, and grammatical
aspects of language.
8The Perisylvian Network
- Wernickes area includes the posterior part of
auditory association cortex in BA22 and its
adjacent heteromodal fields in BA39-40 and
perhaps BA21. - Wernickes area displays a specialization for the
lexical and semantic aspects.
9The Perisylvian Network
- Additional components of this network are located
in the striatum, thalamus, and the association
areas of the frontal, temporal, and parietal
lobes. - Damage to this network in the left hemisphere of
the majority of the population yields aphasia,
alexia, and agraphia. - Linguistic processes in the brain can be broadly
divided into those that link thought (or meaning)
to word forms (lexical-semantic) and those that
sequence words and word endings to convey
relationships among words (syntactic).
10The Perisylvian Network
- Aphasia refers to a disturbance of either one of
these components, reflected in abnormalities of
oral or written communication. - The classical aphasia syndromes are based on
patterns of deficits in spontaneous speech,
comprehension of oral and written language,
repetition, naming, and writing. - The aim of the language examination is to
identify whether lexical-semantic or syntactic
processes are primarily affected and also to
categorize the aphasia according to the classical
syndromes.
11Left Hemisphere Lesions
- For over a century, people with brain damage have
been recognized as displaying different
combinations of symptoms related to specific
areas of brain injury. - When damage occurs in certain functional areas,
such as the primary or association cortices, a
specific kind of impairment in linguistic element
processing may result. - When damage is not discrete, as in cases of
diffuse axonal injury, or large vessel
infarctions, the resulting pattern of impairment
often presents a mixture and overlap of symptoms.
12Left Hemisphere Lesions
- Although we will utilize the term aphasia in
connection with prototypic disturbances in
language function, keep in mind that aphasia is
an umbrella term encompassing a wide variety of
language dysfunctions, on the receptive/comprehens
ion and expressive/production continuum. - We will also look at communication function
within the left hemisphere along the horizontal
organization continuum of the posterior to
anterior regions.
13Posterior Language Zones
- The posterior language zone in the dominant left
hemisphere includes the middle and posterior part
of the first, second, and third temporal gyri,
Heschls gyrus, the inferior parietal lobule,
including the supramarginal and angular gyri.
14Posterior Language Zones
- The nuclear region of the posterior language zone
is situated in the posterior part of the first
temporal gyrus (unimodal Wernickes area) and in
the adjacent areas of the middle first temporal
gyrus, Heschls gyrus, the posterior portion of
the second temporal gyrus, and the angular gyrus.
15Posterior Language Zones
- In the syndromes of posterior aphasia, the
following characteristics are frequently present - addition of functional words in expressive
speech - disturbances of phrase comprehension
- alienation of word meaning
- disorders of naming
- semantic and phonemic paraphasias
- decreased awareness of verbal expression errors
- problems with auditory phoneme and word
comprehension - sensory aprosody and
- increased speech activity.
16Areas of Linguistic Processing Impairments
- The superior temporal gyrus is the site of
auditory input language interpretation. - Damage to this area makes for difficulty
discriminating speech sounds, distinguishing
syllables/words which sound familiar, analyzing
words into component sounds, or resynthesizing
them.
17Superior (1st) Temporal Gyrus
- Words become vague and undifferentiated,
affecting comprehension. - Expressively, language is empty, frequently
circumlocuted, and littered with semantic
paraphasias. - Neologisms for nouns and verbs are common.
- A module for auditory sequential memory is
thought to reside just lateral to Heschls gyrus. - Word repetition may be made difficult by
instability of retained auditory sequences
18Angular Gyrus (Area 39)
- The angular gyrus, at the juncture of the
temporal, parietal, and occipital lobes, is
thought to be the module site for word meaning. - A lesion to this area disturbs naming and
alienates word meaning for body parts and
space-time relationships. - With lesion extension into the occipital and
parietal areas, alexia and agraphia may result.
19Supramarginal Gyrus (Area 40)
- The supramarginal gyrus, found curving around the
lateral sulcus, is thought to be the module site
for abstraction and integration of sensory
information necessary for naming.
20Supramarginal Gyrus (Area 40)
- A lesion in this area produces phonological
processing errors, called phonemic paraphasias,
in contextually appropriate lexical items in the
form of substitutions (dite/kite), deletions
(reen/green), and transpositions (predesent/ - president).
21Anterior Language Zone
- The anterior language zone in the dominant left
hemisphere includes the posterior part of the
third frontal gyrus, also known as Brocas area,
the lateral operculum, the insula, and the
posterior part of the first and second frontal
gyri.
22Anterior Language Zone
- On the mesial surface of the left hemisphere,
this zone includes the supplemental motor area
and the anterior cingulate gyrus.
23Anterior Language Zone
- Syndromes of anterior aphasia are generally
characterized by - telegraphic style, with a predominance of
substantive words - lack of grammatical functor words
- impoverishment of speech, reduced to short
phrases and high-frequency words - relatively preserved comprehension and naming.
- In anterior aphasia, motor elements are present
and consist of deformation of articulation, motor
dysprosody, aphonia, hypophonia, and decreased
speech activity.
24Brocas Area (44)
- Delineated as a premotor zone in the inferior
(3rd) frontal gyrus, Brocas area is the module
site thought to program the oral and phonatory
mechanism for speech movements. - A lesion in this area would likely produce
phonetic-articulatory sequencing deficits in
syntactically normal utterances, evidencing motor
dysprosody and perseverations.
25Premotor Gyrus (Area 6)
- A lesion in the left premotor gyrus may result in
a nonfluent aphasia characterized by strings of
content words, lacking grammatical functors
(agrammatism). - Impaired prosody is usually reflected in a
tendency to drop unstressed syllables,
inflections, and auxiliaries.
26Supplemental Motor Area (Area 8)
- A lesion in the supplemental motor area, located
in the medial frontal cortex, may result in
partial mutism initially, eventually resolving to
some spontaneous speech, some repetition, and
naming. - Difficulty initiating spontaneous speech usually
prevails.
27Anterior Cingulate Gyrus (Area 24)
- Bilateral damage to the anterior cingulate gyrus
results in akinetic mutism, with no evidence of
preserved language comprehension. - With recovery, speech returns through aphonic
whispering and hoarseness. - Aphasia and motor speech components are absent.
28Mixed Anterior-Posterior Zones
- Lesions can involve aspects of both anterior and
posterior language zones. - Salient symptoms of mixed aphasia include loss of
expressive speech, graphic, and gestural output,
and a noticeable lack of auditory comprehension. - This is an apparently global aphasia.
29Right Hemisphere Processing
- The right hemisphere is preferentially devoted to
processing of stimuli characteristics related to
visuo-spatial, bodily, and affective domains. - Damage to the right hemisphere results in some of
the most bizarre and complex syndromes observed
in clinical medicine. - Visual hallucinations, denial of illness,
unilateral neglect, amnesia for nonverbal
material, and loss of speech prosody are among
the unusual usual symptoms exhibited by clients
with RH injury. - Direct categorization of clinical syndromes by
specific modules/regions is difficult because
there is frequent regional overlap of network
components. - Instead, disorders are categorized by the
underlying neuropsychological processing
abnormalities.
30Right Hemisphere Networks
- There are a number of different networks that can
found within the right hemisphere - a right-hemisphere spatial attention network with
epicenters in the dorsal posterior parietal
cortex, the frontal eye fields, and the cingulate
gyrus - a right-hemisphere face and object recognition
network with epicenters in the middle temporal
gyrus and the temporal pole and - a prefrontal network involved in working memory
and executive function.
31Dorsal Parieto-frontal Network
- The spatial orientation network consists of three
interconnected cortical epicenters around the
intraparietal sulcus, the frontal eye fields, and
the cingulate gyrus.
32Dorsal Parieto-frontal Network
- The parietal component is specialized for the
perceptual representation of behaviorally
relevant locations and their transformation into
targets for attentional actions. - It receives many and various inputs including
visual, auditory, somaesthetic, limbic and motor
output signals.
33Dorsal Parieto-frontal Network
- The frontal component, the frontal eye fields
(FEF), are located along the superior lateral
convexity. - The FEFs coordinate and maintain eye and head
movements, gaze shifts, and thus orienting and
attentional reactions in response to
predominantly visual, but also tactile and
auditory stimuli.
34Dorsal Parieto-frontal Network
- It is also involved in focusing attention on
certain regions within the visual field, as well
as in making smooth pursuit movements and perhaps
guiding eye movements while reading and when
writing. - The cingulate gyrus has a specialized role in the
distribution of effort and motivation.
35Dorsal Parieto-frontal Network
- The anterior portion is thought to engage in
global attention. - The posterior part is thought to participate in
differentiated lateralized shifts of motivational
relevance and focalized attention.
36Dorsal Parieto-frontal Network
- Damage to this network in the right hemisphere
yields deficits of spatial attention and
exploration. - Contralesional hemispatial neglect occurs almost
exclusively after right-sided damage to this
network and is characterized by the reduction of
neural responses that can be mobilized by sensory
events located on the left and by motor plans
directed to the left. - When neglect is severe, the patient may behave as
if one-half of the universe had abruptly ceased
to exist in any meaningful form (Mesulam, 2000).
37Dorsal Parieto-frontal Network
- Damage to this network in the right hemisphere
yields deficits of spatial attention and
exploration called hemispatial neglect - It is characterized by the reduction of neural
responses that can be mobilized by sensory events
located on the left and by motor plans directed
to the left. - When neglect is severe, the patient may behave as
if one-half of the universe had abruptly ceased
to exist in any meaningful form (Mesulam, 2000).
38Dorsal Parieto-frontal Network
- When both the right and left sides of the
occipito-parietal cortex is damaged, this pattern
of damage often results in Bálints syndrome, an
acquired disturbance of the ability to perceive
the visual field as a whole. - Holistic visual field perception is affected by
the inability to perceive more than one object at
the same time (simultanagnosia), which is
accompanied by an impairment of target pointing
under visual guidance (optic ataxia) and an
inability to shift gaze at will toward new visual
stimuli (ocular apraxia).
39Dorsal Parieto-frontal Network
- Such patients are essentially blind outside the
focus of their attention, and cannot locate,
reach for, or track the spatial movements even of
items that are within their focus of attention. - In some ways, this represents the complete
dissolution of spatial awareness which Balint
described "as if there is no there, there."
40Ventral Occipito-temporal Network
- The transmodal epicenters for the face and object
recognition network are located in the middle
temporal gyrus and the temporal pole. - Additional critical components are located in the
fusiform gyrus and the inferior temporal gyrus.
41Ventral Occipito-temporal Network
- Damage to this network yields recognition
deficits such as object agnosia and
prosopagnosia, agnosia for faces. - The lesions that cause such deficits are almost
always bilateral. - The fusiform gyrus is the most common site of
lesions, probably because it is the only part of
this network with a vascular supply that makes
bilateral damage likely.
42Prefrontal Network
- The prefrontal heteromodal and orbitofrontal
cortices are the major epicenters involved in the
coordination of comportment. - The prefrontal heteromodal cortex and the
posterior parietal cortex provide epicenters for
a network involved in working memory and related
executive functions.
43Prefrontal Network
- Deficits of comportment are more frequently
associated with a lesion of the orbitofrontal and
adjacent medial frontal cortex. - Deficits of executive function and working memory
are more frequently associated with damage to the
dorso-lateral prefrontal cortex. - Clinically significant deficits are usually seen
only after bilateral lesions. - Unilateral right-sided lesions can give rise to
behavioral disinhibition.
44Right Hemisphere Impairments
- The formal linguistic components of communication
are enhanced and modified by facial expressions,
gestures, body posture, speech prosody, and other
paralinguistic signals. - Right-sided cerebral lesions may result in
specific deficits in the comprehension and
production of both affective and emphatic prosody
and with the nonverbal identification of facial
affect. - They may also interfere with the ability to
adjust interpersonal behavior to social context,
such as turn-taking, style switching to fit
audience, and maintaining appropriate
interpersonal distance.
45Right Hemisphere Impairments
- Complex perceptual and spatial processing is
needed for constructions, dressing, and spatial
distribution of attention. - Constructional abilities entail complex
perceptual, motor, and executive functions
required by tasks such as drawing, assembling
puzzles, and constructing designs from blocks or
sticks. - In construction, the right hemisphere is thought
to maintain the overall configuration of the
design, whereas the left hemisphere is thought to
process internal detail.
46Right Hemisphere Impairments
- Patients with right hemisphere lesions may employ
a piecemeal or disorganized approach to
construction tasks, overlooking the large
picture. - Impairments of the ability to dress oneself can
take different forms. - With right hemisphere posterior parietal lobe
lesion, the difficulty may be confined
exclusively to dressing the left side of the
body, possibly due to hemispatial neglect. - A more generalized dressing apraxia has to do
with the inability to align the axis off a
garment with the body axis.
47Right Hemisphere Impairments
- Deficits associated with occipital lobe damage
include disorders of color perception, disorders
of visual processing, and disorders of
visuo-verbal processing. - Deficits associated with parietal lobe damage
include difficulty recognizing visuospatial
information, impaired recognition of objects in
unfamiliar views, and difficulty with spatial
orientation. - Other deficits associated with right parietal
damage include difficult sustaining attention,
hemispatial neglect on the side contralateral to
the lesion, unawareness or denial of deficits,
and difficulty with orientation and location in
space.
48Right Hemisphere Impairments
- Difficulties associated with right temporal lobe
damage include deficits in processing music and
deficits in nonverbal memory. - Deficits associated with frontal lobe damage
include difficulty with planning and
problem-solving, decreased behavioral initiation
and spontaneity, distractibility, perseveration,
and poor memory for order of sequence of events.
49Occipital Lobe Damage
- Lesions to the occipito-parietal and
occipito-temporal areas produce a variety of
visual processing difficulties. - Prosopagnosia, or agnosia for faces, is an
acquired deficit in the recognition and
identification of previously known and familiar
human faces (e.g., Oliver Sacks The Man Who
Mistook His Wife for a Hat). - Patients have adequate visual acuity, but they
are unable to recognize or identify family,
friends, famous persons, or even their own
reflection in a mirror.
50Occipital Lobe Damage
- If the disorder is severe, patients may be unable
to distinguish between male and female, human and
animal, and young and old faces. - They often recognize people known to them by
their voice, clothing and accessories, body size,
hair color, or gait. - Topographagnosia, or environmental agnosia, is
the acquired loss of the ability to recognize
visual stimuli relating to a persons
environment. - The environment is perceived as different,
unfamiliar, or unrecognizable. - The person has trouble finding his/her room,
home, locating public buildings in a specified
area, or drawing a map of how to get to a
specific location.
51Occipital Lobe Damage
- A lesion to the inferior visual association
cortex, in the absence of retinal pathology,
results in achromatopsia, an acquired disorder of
color perception, characterized by a loss of
color vision in all or part of (quadrant or
hemifield) the visual field. - Lesions in the right occipital cortex also can
produce reading problems that arise from gaze
instability, spatial neglect, or other defects in
visual processing, as opposed to more
linguistically based disorders of reading.
52Occipital Lobe Damage
- Hemialexia, the loss of reading ability in one
visual hemifield, may occur in the RH patient
with severe neglect. - The left side of words or sentences may be
neglected with varying degrees of awareness. - The majority of reading problems that occur as
sequelae of right hemisphere injury are derived
form some combination of visual processing
deficits, including visuo-perceptual,
visuo-spatial, and/or visuo-verbal decoding
difficulties.
53Parietal Lobe Damage
- A salient feature of RH syndromes is a group of
related disorders characterized by deficits in
corporeal awareness. - Patients experience impaired awareness of self
and alterations in their body image, ranging from
uncritical underestimation to explicit,
intractable denial of phenomena. - Autopagnosia is the inability to indicate various
parts of the body, either by pointing to them on
command, naming them, or matching them to
pictures or parts on the examiners body.
54Parietal Lobe Damage
- Anosodiaphoria is a term first coined by Babinski
in reference to the lack of concern shown by
patients with hemiplegia. - Although aware of their paralysis, some patients
exhibit carefree indifference and inadequate
insight as to the implications/consequences of
the condition. - Unilateral neglect is a syndrome in which the
ability to direct attention to important events
in one half of personal and extrapersonal space
is compromised. - The patient fails to attend to, respond to, or
report stimuli in that hemispace. - Motor, sensory, visual, and auditory modalities
can be affected.
55Parietal Lobe Damage
- Asomatognosia refers to the feeling of
nothingness described by some patients with
hemiplegia who report they feel the limb is
missing or that there is nothing to the left of
midline of the body. - Hyperschematia refers to a disorder in which the
patient feels as though the affected appendages
are swollen or heavy. - Some have referred to these appendages as dead
wood or dead meat. - Misoplegia is hatred of the paralyzed limb.
- Personification refers to the attempt by the
patient to name or otherwise anthropomorphize the
affected limb, treating it as another person.
56Parietal Lobe Damage
- Somatoparaphrenia refers to a paranoid reaction
to the paretic limb, specifically the belief that
the paretic limb has undergone some sort of
horrid transformation by some mechanical
manipulation. - Supernumerary phantom refers to a condition in
which the patient imagines that there is an extra
or third limb on the affected, hemiplegic side,
which is not in the position in space where the
actual limb lies. - These additional limbs are often reflected in
patient drawings. - Denial syndromes are also common with parietal
lobe damage. - Denial involves negation or refusal to accept a
disability or condition it can be explicit or
implicit.
57Parietal Lobe Damage
- Explicit denial ranges from minimization and
temporal displacement of the disability to
complete denial or projection of the disability
outside the self. - Example 1 A man with a self-inflicted gunshot
wound to the head which penetrated the brain
attempted to explain his skull fracture and
subsequent hospitalization by stating that he had
tripped over the cat and hit his head on a gulf
ball. - Example 2 A woman with a right CVA and severe
left hemiplegia stated that she was in the
hospital for the examiners wedding and was just
resting until the ceremony began.
58Parietal Lobe Damage
- Implicit denial involves disinterest in,
inattention to, or lack of reaction to the
paralyzed side of the body. - The individual may fail to dress that side of the
body or respond to threatening or painful stimuli
on that side of the body. - Disorders of praxis are disorders of learned
movement that cannot be adequately explained on
the basis of attentional deficits, weakness of
musculature, sensory loss, or comprehension
deficits. - Common with right posterior or parietal lobe
lesions are dressing apraxia and constructional
apraxia.
59Parietal Lobe Damage
- Dressing apraxia is an impairment in the ability
to dress oneself due to complex visuospatial
deficits and sequencing difficulties. - Body-garment disorientation is characterized by
the inability to orient ones body part to the
appropriate garment or portion of the garment to
accomplish the logistics of dressing. - The garment may be turned backwards out or inside
out, and/or the left and right may be inverted or
the up and down. - Constructional apraxia is manifested as a
difficulty in putting together one-dimensional
units so as to form two-dimensional figures or
patterns.
60Parietal Lobe Damage
- People with this disorder do not have difficulty
making most types of skilled movements with their
arms and hands. - They have no trouble using objects properly,
imitating their use, or pretending to use them. - The primary deficit in constructional apraxia
appears to involve the ability to perceive and
imagine geometrical relations.
61Parietal Lobe Damage
- The defect can be seen in copying a visually
presented object or design, assembling block or
stick patterns, or in free drawing. - Because of this deficit, a person cannot draw a
picture, say, of a cube, because he/she cannot
imagine what the lines and angles of a cube look
like, not because of difficulty controlling the
movements of his or her arm and hand.
62Loss of Hemispheric Integrity
- Various disorders of language processing, general
behavior and psychic integrity, and visual
symbolic processing arise when the right
hemisphere is damaged and there is loss of
bihemispheric integrity. - Right hemisphere damage can affect the following
language processing skills prosody, affective
language, integrative appositional language and
pragmatics. - Although the experience of emotion is mediated by
the limbic system, a system with bilateral
representation, expression of both emotion in the
voice and face and the perception of emotion in
voices and faces is dependent upon lateralized
right hemispheric mechanisms.
63Loss of Hemispheric Integrity
- Right-sided lesions can impair speech prosody
without altering the propositional content of
verbal output. - Specifically, a lesion in the right frontal and
anterior parietal area may result in a patient
demonstrating good comprehension of speech
prosody, but impaired spontaneous and imitative
prosody. - In patients in whom the lesion affects only the
parietal area, comprehension of prosodic speech
elements may be lost, but not the propositional
content of language. - Such patients may also have difficulty with
imitative prosody.
64Loss of Hemispheric Integrity
- Because the right hemisphere processes language
more holistically than the left hemisphere,
damage to the right hemisphere may cause problems
in utilizing context to extract the main point or
moral of a story, or to draw inferences, in spite
of the fact that the ability to recall isolated
details may be preserved. - Right hemisphere injured individuals may also
have problems interpreting abstract and
figurative language, such as proverbs, idioms,
and metaphors. - Typically, they render a more concrete and
literal interpretation of abstract language.
65Loss of Hemispheric Integrity
- Comprehension of humor also appears impaired.
- Individuals with pre-central right hemisphere
lesions demonstrate more exaggerated responses to
humor, while individuals with post-central
lesions demonstrate an overall flattened
response. - Inappropriate use of humor or off-color remarks
in conversation is also frequently noted. - The conversational style of RH individuals has
been characterized as verbose and tangential.
66Loss of Hemispheric Integrity
- Frequently, insignificant details and
inappropriate personal remarks, and knowledge
presupposition accompany the verbosity. - Individuals may also have difficulty organizing
and ordering information, and making a point in
conversation. - In addition to problems with organizing
information, individuals with RH injury often
have difficulty with the social uses of language
interaction.
67Loss of Hemispheric Integrity
- Some areas in which pragmatic disturbances are
evidenced include proxemics, use of gesture,
question formulation, comment interjection,
assertion, requesting, conversational initiation,
especially of a novel topic, topic change, topic
selection, topic maintenance, turn-taking, repair
and revision, and judging pause time between
turns and interrupting. - The quality of verbal and non-verbal feedback to
the speaker may also be impaired, e.g., eye
contact. - They may be perceived as rude by family
members, friends, and staff as the result of
their lack of impulse control and social
appropriateness, characterized by such things as
undue familiarity, talking excessively, and
violating the polite rules of conversation.
68Loss of Hemispheric Integrity
- Alterations in sexual behavior and sexual
function including inappropriate sexual advances
and lewd comments have been noted in patients
following RH injury. - Altered sexual behavior may range from open
masturbation, exposure, and overt verbal and
physical sexual advances toward staff members to
delusions with sexual content and confabulations
concerning sexual activity. - Some of these individuals may become preoccupied
with body functions, such as bowel and bladder
control, and may insist on receiving a physical
means of expression, such as touch, from their
caregivers.
69Loss of Hemispheric Integrity
- Weinstein and Kahn (1955) described the case of a
63-year-old woman with left homonymous
hemianopsia, left astereognosis, reduced
two-point discrimination, position sense, and
point location in the left hand, right-left
discrimination problems, dressing apraxia,
topographic disorientation, and left neglect
secondary to thrombotic obliteration of the
middle cerebral artery. - She was delusional and thought the man visiting
her roommate was a mechanical dentist.
70Loss of Hemispheric Integrity
- In her conversation with the examiner, she
stated, Do you mind if I bother you?well, I
like to be hot and bothered. Im propositioning
you. I havent been hot and bothered for a long
time. - The same patient remarked that her roommate was
noisy because she wanted to be laid. - Reportedly, the patient exposed herself
constantly and had to be placed in restraints due
to frequent picking of her anus and genital area.
71Loss of Hemispheric Integrity
- Disturbance of mood is also common with right
hemisphere injury. - Flatness or indifference reaction (indifference
to or minimization of symptoms) is seen in most
patients with only minor right hemisphere injury
in contrast to the emotion-laden catastrophic
reactions of left brain injured patients. - Depression is difficult to diagnosis in RH
individuals because of external affective
disturbances (i.e., sad-looking face, vocal tone,
flat affect). - The individual may actually harbor a full
component of concern, even to the extent of
suicidal depression, without being able to
physically express it.
72Loss of Hemispheric Integrity
- Conversely, the patient may appear depressed
because of the depressed affect, but not be
experiencing depression. - Some RH individuals may experience agitated
confusion, delirium, disorientation, and various
psychotic states. - Agitated confusion is characterized by incoherent
thought patterns, severe reduction in attention
span, extreme distractibility, restlessness,
disruption of goal-directed behavior,
disorientation, and sometimes violent outbursts. - Psychotic symptoms can include hallucinations and
paranoid delusions. - These symptoms may pass in a few days or, in some
cases, may last for months.
73Loss of Hemispheric Integrity
- Although rare, several specific delusions have
been associated with RHD. - Together they can be called misidentification
syndromes. - These include misidentification of place,
persons, or body parts. - Often these delusions occur in isolation without
other symptoms of confusion. - Misidentification of persons and place, or
reduplicative paramnesia, results in patients
thinking that familiar persons or places have be
duplicated.
74Loss of Hemispheric Integrity
- With misidentification of place, they may
recognize that they are in a hospital, but
confuse it with a hospital they were in
previously. - They may think they are in their bedrooms at home
or that the hospital is attached to their houses,
etc. - Misidentification of persons or Capgras syndrome,
refers to the delusion that others, but not the
self, have been replaced by doubles. - Typically, people with Capgras syndrome consider
the duplicates or doubles as dangerous or
frightening.
75Loss of Hemispheric Integrity
- Another form of misidentification of persons is
Fregoli syndrome. - This form of misidentification involves the
delusion that the known person is changing his
appearance dramatically. - For example, a RHD patient was convinced that the
woman in the bed next to her was her husband, and
that he was flirting with the nurses. - She became angry and confused when her actual
husband came to see her on his daily visits.
76Summary of RHD
- Patients with RHD can have a variety of deficits,
some of which can affect communication and
cognition directly, and some of which exert
indirect effects on the ability to participate in
communicative events and to interact successfully
with the environment. - Just as not all adults with damage to the LH are
aphasic, not all RHD adults have problems in
perception, cognition and/or communication. - The typical RHD patient almost always
communicates adequately in superficial
conversation.
77Summary of RHD
- There may be a flatness in the voice and affect
and a general sense of reduced arousal, but as
long as the conversation is brief and covers
familiar territory, one might not detect any
communication deficits. - Problems begin to emerge in more extended and
complex conversation. - Patients may seem disinterested and somewhat
insensitive as communicative partners. - They may begin and end conversations abruptly,
fail to follow social conventions, and even
appear rude.
78Summary of RHD
- They may interrupt and fail to make eye contact.
- If they are no longer interested in what someone
is saying, they may turn without apology to
something else, apparently unaware of the
disruption to the conversational flow. - They may be perfunctory, making the least
effortful response to questions, regardless of
the consequences of their answers. - Alternately, they may be verbose and rambling.
- They may have trouble getting to the point.
79Summary of RHD
- Their discourse may seem to be made up of an
assembly of facts without the glue that holds
them together in an overriding structure. - They may be led by internal associations to
related but tangential issues, as if they are
thinking out loud, rather than having a
conversation. - As listeners, they may focus on bits of
information in a piecemeal way without
integrating them into the larger picture.
80Summary of RHD
- They may fail to respond to situational variables
that specify the nature of the communicative
eventlighthearted banter, serious discussion,
superficial social exchange. - They may have problems recognizing when people
are kidding, sarcastic, or ironic. - Patients with RHD may appear distant, remote,
bound up in themselves. - They may have trouble adopting other peoples
point of view, or recognizing what their
listeners know and what they do not know.
81Summary of RHD
- The may show little appreciation for shared
knowledge and may not take contextual variables
into consideration. - Vague references to unfamiliar people, places,
and events, may force the listener to make the
connections that have been omitted. - Their capacity to attend may be reduced or fade
in and out so that they miss crucial information. - They may have trouble interpreting others
intended meanings, and have difficulty conveying
their own. - They may have difficulty following the gist of a
conversation, written narratives, television
news, etc., if the information is presented too
quickly or when the core concepts are subtle and
require high levels of inference.
82Summary of RHD
- Failure to admit to confusion and uncertainty can
accompany reduced insight about physical and
cognitive problems. - Denial of deficit or denial of illness often
gives the impression that RHD patients are
unconcerned about their current status and future
adjustments. - Failure to respond appropriately to their
deficits is characteristic of patients who have
left-neglect. - These patients may not notice their left arm
dragging in their wheel chair spokes. - They may not attend to people, events, or even
sounds to their left.
83Summary of RHD
- If patients have diffuse RHD, affective
disturbances such as agitated confusion and
certain types of delusions may be apparent. - Patients with more focal RHD who are not
otherwise confused may confabulate elaborate
justifications to cover for cognitive
uncertainty. - It can occur as they try to negotiate information
that is conflicting, ambiguous, makes no sense to
them, and/or makes no sense to others. - Rather than questioning, reflecting, analyzing,
or dismissing it, they construct elaborate
explanations to justify it, as if all must be
right with the world or something may be wrong
with them.
84Summary of RHD
- Finally, patients with RHD may appear
unresponsive to the emotional tone of the
exchange and may have problems conveying their
own emotions through prosody, facial expression,
gesture, and body language. - Their speech may be flat and uninflected.
- Their words may be embedded in some sort of
stereotypic prosodic pattern that does not
differentiate well among sentence types or
emotional content, making listening difficult. - Some patients, because of the size and/or site of
their lesions, or because of the way their
particular brains are wired, may be almost free
of these signs.
85Summary of RHD
- Among those that do have cognitive and
communicative deficits, there is a range of
impairment. - Communication disorders may be obvious or subtle,
however for the listener, there is a sense of
someone using language, but not as effectively as
expected. - In other words, there is a sense that someone is
communicating, but not quite connecting.